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1 Thank you for joining us! Dial the phone# below to ensure connection to the audio portion of this webinar: Call-in number: INSERT PHONE NUMBER Meeting ID: INSERT MTG I.D. Please mute phone lines We will start promptly at 11am (eastern) If experiencing technical difficulties send chat to Host: INSERT HOST NAME or call (XXX) XXX-XXXX

2 Harm Reduction Approach WEBINAR October 5, am-1pm eastern standard time Emma Roberts Director of Capacity Building Joanna Berton Martinez Senior Trainer

3 *MUTE* your phones please!

4 Harm Reduction Coalition Founded in 1993 by needle exchange providers, advocates, and drug users. National advocacy and capacity-building organization to promote the health and dignity of individuals and communities impacted by drug use. Our work is driven by a commitment to drug user rights and social inclusion of marginalized communities. POLICY & ADVOCACY TRAINING & CAPACITY BUILDING OVERDOSE PREVENTION & SYRINGE ACCESS NATIONAL & REGIONAL CONFERENCES RESOURCE & PUBLICATIONS

5 National Conference 2016 November 3-6 San Diego!

6 Webinar Details Mute the telephone you are using, please. The last 30 minutes are reserved for Questions. We will use Chat Box through out the workshop to check-in on today s content, too.

7 Step 1 Chat Box Directions Step 1 Activate the chat feature at the top of the screen by clicking the chat bubble Step 2 In the send to bar, select Host & Presenter to be sure your question reaches the moderators Step 2 Step 3 Type your question in the chat box and click *Send*

8 Chat Box Chat Box is located on the bottom right of the screen. Hit Reply All if you want everyone to get the message. It s okay to send your question or response directly to us, too (don t hit Reply All).

9 1. Training Overview

10 Who this training is for: Health and human service providers in the general public, with an interest in preventing HIV/AIDS. What this training is about: This workshop will provide an overview of Harm Reduction. We will look at harm reduction as a practical set of strategies that are designed to prevent disease and promote health.

11 Agenda 1. Training Overview 2. Harm Reduction 3. Drug Use 4. Sexual Activity 5. Strategies 6. Questions & Answers

12 Workshop Goal The goal of this webinar is to provide an introduction to basic philosophy and practices of HIV/STI/Hep C harm reduction with regards to substance use and sexual risk behavior.

13 Training Objectives By the end of this training, you will be able to: 1. Define harm reduction as it is used in HIV/STI/Hep C prevention; 2. List at least three elements of the harm reduction model; 3. Identify at least three attitudes about using a harm reduction approach; 4. Identify at least three examples of harm reduction options for substance use behaviors and sexual behaviors; 5. Identify negotiated safety techniques for injection risk reduction and sexual risk reduction.

14 Glossary PWID PWUD PLWHA STI SAS SSP ESAP People Who Inject Drugs People Who Use Drugs People Living with HIV/AIDS Sexually Transmitted Infection Syringe Access Services Syringe Service Programs Expanded Syringe Access Program

15 Sexual Orientation To whom we are sexually attracted. Gender Identity Sense of self as male or female, neither or both. PGP Preferred Gender Pronoun LGBTQ Lesbian, Gay, Bisexual, Transgender, Queer/Questioning

16 2. Harm Reduction

17 Why Is There A Need For Harm Reduction? Respond to disproportionate disease and fatality rates Reach vulnerable populations Keep individuals engaged if they relapse or are not abstinent from drugs or sex

18 2015 outbreak in rural Indiana linked to PWID needle sharing: 170 people infected with HIV Since 2000, the rate of deaths from drug overdoses involving opioid pain relievers and heroin increased 200% 56% of black transgender women had positive HIV test results compared to 17% of white or 16% of Hispanic transgender women Centers for Disease Control and Prevention

19 Almost 45% of estimated new HIV diagnoses in the U.S. were among African Americans, who comprise 12% of the U.S. population. More than 25% of that 45% were women. 7 in 10 new HIV diagnoses among Hispanics occur in gay and bisexual men. Centers for Disease Control and Prevention

20 What Good Comes Out of Harm Reduction? Challenge Stigma Increase Trust with Clients and Foster Engagement Improve Public Health with Individuals and Community-wide

21 Harm Reduction is A set of practical strategies to reduce negative consequences of drug use and sexual risk. Incorporates a spectrum of strategies including safer techniques, managed use, and abstinence. Meets people where they're at but doesn't leave them there.

22 Does not attempt to minimize or ignore the harms associated with licit and illicit drug use and sexual activity. Applies evidence-based interventions to reduce negative consequences of these behaviors. Ex: syringe access, naloxone, PrEP

23 Moves past judgment of another person to address their drug use and sexual activity and the harm that s occurring to that person. Works to elicit ANY POSITIVE CHANGE based on individual client need, circumstance, and readiness to change.

24 What Harm Reduction is Not Harm reduction does not mean anything goes. Harm reduction does not condone, endorse, or encourage drug use or high risk behaviors. Harm reduction does not exclude or dismiss abstinence-based treatment models as viable options.

25 Levels of Harm Reduction Individual Community Institutional

26 Harm Reduction A holistic approach to working with people at higher-risk in relation to HIV, drug use, and sexual behaviors. Programs can be: Low-Threshold, Convenient, Evidence-based Providers can be: Positive - Honest - Productive Pragmatic - Client-centered - Without Bias

27 Continuum of Use No Use Experiment Situational Use Severely Persistent Chemically Dependent Social & Ritual Use Binge Use Abuse Habit Chronic

28 The degree of harm associated with a risk behavior may vary based upon numerous factors, including drug, set, and setting.

29 Drug, Set, And Setting: The Basis for Controlled Intoxicant Use. Zinberg, N. E. (1984)

30 Key Principles of Harm Reduction Health and Dignity Participant-Centered Participant Involvement Participant Self-Rule Recognize Inequalities and Injustices Practical and Realistic

31 foto by George Hodan (1) Health and Dignity Providers treat program participants with respect.

32 foto by Maliz Ong (2) Participant-Centered Providers offer services without judging the participant. Programming is low-threshold and accessible.

33 (3) Participant Involvement Providers ensure the people you are serving have a real voice in the creation of programs and policies designed to serve them.

34 foto by CDC/James Gathany (4) Participant Self-Rule Providers recognize participants are experts in their own lives. It is the participant who makes their own changes, when they feel they can make them, under their own circumstances.

35 foto by Peter Griffin (5) Impact of Inequalities and Injustices Providers recognize complexities of poverty, class, racism, isolation, past trauma, sex-based discrimination and other inequalities affect people's vulnerability, and capacity for effectively dealing with behavior-related harm.

36 HRC Hepatitis C Prevention Poster (6) Practical and Realistic Providers offer practical tools and education to address the real harms and dangers experienced by individuals with significant risk.

37 *CHAT BOX* Approach the keyboard if you d like to share what you think

38 1) Which Principle is most Challenging? Health and Dignity Participant-Centered Participant Involvement Participant Self-Rule Recognize Inequalities and Injustices Practical and Realistic

39 2) Which Principle Resonates the most? Health and Dignity Participant-Centered Participant Involvement Participant Self-Rule Recognize Inequalities and Injustices Practical and Realistic

40 3. Drug Use

41 What are some risk factors surrounding drug use?

42 People will have different reasons for using substances. Considering factors surrounding these behaviors will be useful when brainstorming options to reduce risk for disease transmission.

43 Factors Related to Drug-Use Drug What type of drug if it is liquid, pills, powder, gooey tar Potency of drug might be less difficult to determine with prescription pills than illicit street drugs What the drug is cut or mixed with household cleaners or poisonous and not designed for human consumption Fentanyl, a strong opioid that can increase overdose

44 Set In withdrawal will change circumstances regarding drug prep, drug use (e.g., not applying best practices for disease prevention in prep, using in public place) Taking care of business when not in withdrawal PWUDs are not in a constant state of withdrawal, can take steps to cover basics (food, rent, cell phone) and set aside money for drug cultivate more than one dealer

45 Setting Unstable housing or homelessness using in public or in compromised settings Access to clean water if there is sterile or running water available to wash, drink to re-hydrate, or dissolve drug Using used needles only have one left (confiscated, busted, did not have a chance to visit SAP, no where to put sterile gear) Using alone no overdose response if occurs, people think you re not using anymore so difficult to ask for help Injected by another person unable to determine how much drug used, unable to use without this person

46 *CHAT BOX* Risk factors surrounding drug use

47 Harm Reduction Options: Drug Use CDC/Amanda Mills How it is consumed smoking a drug or swallowing in pill form will avoid a small hole exposure that results from injecting use own devices for snorting & smoking Hep C can spread from crack pipe or drug straw

48 Managing use small amount of drug first to help determine if it s too strong or just enough have a plan: tell others where to find your naloxone don t use alone, or let someone know when you use clean hands or at least finger tips for drug prep

49 If injecting use new sterile syringe one time only or re-use your own syringe or flush used syringe w. water/bleach/water clean skin with soap and water or clean finger tips with alcohol wipe use own safe injection supplies injecting arms/legs are safer than hands/feet properly dispose of used syringe so no one gets stuck by accident

50 Prevention During Drug Use Clean the skin before injecting to prevent getting an abscess* Use a new, sterile syringe each injection to prevent spread of HIV and Hep B Prevent a fatal overdose with rescue breathing, calling 911, and using naloxone Use safer injection equipment to reduce exposure to Hep C *abscess = swollen, infected sore

51 Doug Wilson Dave Purchase handing out syringes on his own in Tacoma, Wash., in the late 1980s. New York Times, January 27, 2013 Syringe Access Programs Our Roots in Harm Reduction! How does this work? You give me an old one, I give you a sterile one, and it keeps your butt alive

52 Syringe exchange is a sciencebased intervention that does not increase drug use, does reduce HIV + risk for Hep C, and increases the likelihood for program participants to seek treatment.

53 Syringe Access Service Models

54 4. Sexual Behavior

55 What are some risk factors surrounding sexual activity?

56 Factors Related to Sexual Activity Sex What type of sex manual, or use of hands oral vaginal penetration and surface area anal penetration

57 Set If PWUD too, where are they on the drug-use continuum? compromise safer sex options while under influence immediate needs trump using safer sex supplies If trade sex multiple partners, with greater frequency not practical to conduct in-depth risk assessment w. each potential sex partner stigmatized, vulnerable population

58 Setting Unstable housing or homelessness activity in public or in compromised settings less likely to have storage, or carry safer sex supplies Hygiene/Access to clean water able to keep hands, mouth, and body clean in between sexual encounters? Low or no income decisions for survival-based or immediate needs

59 *CHAT BOX* Risk factors surrounding sexual activity

60 CDC/Kimberly Smith, Christine Ford Harm Reduction Options: Sexual Activity Which sexual activity using hands for sex is safer than giving oral or taking penetration using lubrication if there is no condom avoid oral with a cold sore; stop the spread of herpes!

61 Managing carry condoms + pocket lube use a silent alarm or let someone know when you leave with another person to have sexual activity, and check-in upon safe return get tested regularly instead of between new partners bring own safer sex supplies to each encounter

62 More ideas chlamydia, gonorrhea and syphilis have a cure, get tested regularly ask for throat culture and anal swab complete Hep A + Hep B vaccination series get tested for HIV and Hep C carry handy-wipes use mouth wash in between encounters, wait to brush teeth when done for the day be familiar with menstrual cycle and when it s due: blood is blood, ovulation window around day from first day of period

63 Prevention During Sexual Activity Use condoms, gloves, and finger cots to prevent HIV, STIs, viral hepatitis, unwanted pregnancy See if you are a candidate for PrEP, the daily HIV medication for HIV-negative persons at significantrisk Getting tested for HIV/STIs regularly, instead of before each new sex partner PrEP = Pre-Exposure Prophylaxis

64 Question Which of these can increase risk for harm? A. Unstable housing B. No or low income C. Feelings of isolation D. No access to safer supplies E. Not able to use supplies

65 Contributing Factors & Harms Physical Poor health outcomes Violence OD Psychological Depression Isolation Stigma Social Relationship issues Lack of community Isolation from community Spiritual Isolation Not connecting to life Economic $ to acquire drugs Loss of housing Loss of or trouble finding jobs Legal Discrimination Arrest Incarceration

66 5. Harm Reduction Strategies

67 Because harm reduction interventions and policies are designed to reflect specific individual and community needs there is no universal definition of, or formula for, implementing harm reduction.

68 Education Access Support Linkages

69 How can an agency support participants in reducing drug-related & sex-related risk behaviors? 1.Education 2.Access 3.Support 4.Linkages

70 Use *CHAT BOX* to send us questions

71 Examples for EDUCATION Harm Reduction Strategies: HIV/STI prevention Overdose response Hep C treatment

72 Examples for ACCESS Harm Reduction Strategies: Housing assistance Syringe access Safer sex supplies

73 Examples for SUPPORT Harm Reduction Strategies: Active listening Housing assistance Case management Syringe access Motivational Safer sex supplies Interviewing

74 Examples for LINKAGES Harm Reduction Strategies: HIV/Hep Housing C assistance Treatment Drug/Alcohol Syringe accesstx Mental Safer sex health supplies care

75 *CHAT BOX* More Examples? 1.Education 2.Access 3.Support 4.Linkages

76 True or False? Harm Reduction excludes abstinence as an option to reduce harms related to drug use or sexual activity. Harm Reduction includes abstinence as an option to reduce risk surrounding drugs and sex. It is one of several options a person can apply to addressing their own needs, and what they feel they can do at that time.

77 True or False? Harm Reduction offers options so the person them self can determine what is right for them, at that time. What works for one person may be very different from what another person needs. Harm Reduction provides a bowl of options of which the person can pull from, to utilize when circumstances allow.

78 Reflective Practice: Applied Harm Reduction Identify Identify areas where you may need more support in applying specific harm reduction interventions at work. Explain Describe to a colleague what harm reduction is in your own words. Has your definition changed over time? Apply Does your agency engage key principles of harm reduction? How can you integrate the harm reduction approach into daily work with clients?

79 6. Question & Answer Session

80 Ways to Keep the Work Going Attend our 11 th National HRC Conference this November 2016 in San Diego, CA Take more trainings! Ask us about capacity building

81 HRC thanks you for participating in this workshop!